围术期使用右美托咪定可减少老年患者非心脏手术术后瞻望：一项随机对照试验的系统回顾和Meta分析
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Perioperative dexmedetomidine reduces delirium in elderly patients after non-cardiac surgery: a systematic review and meta-analysis of randomized-controlled trial
背景与目的
谵妄是老年患者非心脏手术术后的常见并发症。本次Meta分析旨在进一步证实右美托咪定（DEX）对老年患者非心脏手术术后谵妄（POD）发生率的影响。
方 法
本次分析收集了PubMed、EMBASE、Cochrane图书馆、Web of Science和护理与相关健康文献累积索引(CINAHL)5个数据库成立至2019年2月24日以来的相关文献。在这项Meta分析中，我们纳入了以上数据库关于比较右美托咪定（DEX）与生理盐水（NS）或其他麻醉药物对老年患者（60岁或65岁以上）非心脏手术POD发生率影响的随机对照试验。对DEX给药方案(开始时间，剂量和给药持续时间，有无负荷剂量)和各种对照药物的给药方案进行了亚组分析。所有分析均采用随机效应模型。
结 果
本次Meta分析共包括11项研究，涉及2 890名患者。结果表明，与对照组相比，DEX能显著降低POD的发生率(相对危险度[RR]，0.47；95%可信区间[CI]，0.38 ~ 0.58；p<0.001)。然而，DEX组中低血压（RR，1.20；95%CI，1.04 ~ 1.39；p=0.01）和心动过缓（RR，1.33；95%CI，1.08 ~ 1.63；p=0.007）的发生率增加。亚组分析显示，与NS（RR, 0.49; 95%CI, 0.37 ~ 0.64; P＜0.001）或其他麻醉药物 (RR, 0.40; 95% CI, 0.26 ~ 0.60; P＜0.001)相比，术中给予右美托咪定（RR，0.43；95%CI，0.33～0.57；P＜0.001）和术后给予右美托咪定（RR，0.38；95%CI，0.27～0.54；P＜0.001）或术后给予负荷剂量的右美托咪定（RR, 0.49; 95% CI, 0.36 ~ 0.69; P＜0.001）可减少POD发生率。拔管时间（标准化平均差，-0.60；95%CI，-1.17～-0.03；P=0.04）和住院时间（平均差，-0.50天；95%CI，-0.97～-0.03；P=0.04）有显著性差异。机械通气持续时间和重症监护病房住院时间的数据量不足以进行Meta分析。
结 论
围手术期使用右美托咪定可降低老年非心脏手术患者POD的发生率，但可增加低血压和心动过缓的发生率。
原始文献摘要
Pan H, Liu C, Ma X, et al. Perioperative dexmedetomidine reduces delirium in elderly patients after non-cardiac surgery: a systematic review and meta-analysis of randomized-controlled trials.[J] .Can J Anaesth, 2019, 66: 1489-1500.
Background Delirium is a frequent postoperative complication in elderly patients after non-cardiac surgery. We performed this updated meta-analysis to ascertain more precisely the efficacy of dexmedetomidine (DEX) on the incidence of postoperative delirium (POD) in elderly patients after non-cardiac surgery.
Methods We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from inception until February 24, 2019. In this meta-analysis, we included randomized-controlled trials comparing the effect of DEX vs normal saline (NS) or other anesthetic drugs on POD incidence in elderly (either≥ 60 or ≥ 65 yr old) patients undergoing non-cardiac surgery. We performed subgroup analyses of the DEX dosing strategy (starting time, dose, and duration of administration, with or without loading dose) and the strategy of various control drugs. A random-effects model was used for all analyses.
Results We included 11 studies involving 2,890 patients in our meta-analysis. The pooled results of these studies revealed that DEX significantly reduced the incidence of POD (relative risk [RR], 0.47; 95% confidence interval [CI], 0.38 to 0.58; P ＜0.001) compared with the control group. Meanwhile, the incidences of hypotension (RR, 1.20; 95% CI, 1.04 to 1.39; P = 0.01) and bradycardia (RR, 1.33; 95% CI, 1.08 to 1.63; P = 0.007) were increased in the DEX group. Subgroup analyses revealed a decrease in POD incidence when DEX was administered intraoperatively (RR, 0.43; 95% CI, 0.33 to 0.57; P＜0.001) and postoperatively (RR, 0.38; 95% CI, 0.27 to 0.54; P＜0.001) with a loading dose (RR, 0.49; 95% CI, 0.36 to 0.69; P＜0.001) compared with NS (RR, 0.49; 95%CI, 0.37 to 0.64; P＜0.001) and other anesthetic drugs (RR, 0.40; 95% CI, 0.26 to 0.60; P＜0.001). There were significant differences in the time to extubation (standardized mean difference, -0.60; 95% CI, -1.17 to -0.03; P = 0.04) and the length of hospital stay (mean difference, -0.50 days; 95% CI, -0.97 to -0.03; P = 0.04). The amount of data for the duration of mechanical ventilation and length of intensive care unit stay were insufficient to perform a meta-analysis.
Conclusion Perioperative dexmedetomidine reduces the incidence of POD in elderly patients after non-cardiac surgery, but this comes at the cost of an increased incidence of hypotension and bradycardia.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：何幼芹 编辑：何幼芹 审校：王贵龙